Post on 20-Jul-2020
Vendor Specifications
278 Healthcare Services
Request for Review and Response
ASC X12N Version 5010
for
State of Idaho MMIS
Date of Publication: 03/30/2020
Document Number: TL418
Version: 7.0
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
Last Updated: 03/30/2020 Page ii
Revision History
Version Date Author Action/Summary of Changes
1.0 07/01/2011 Molina Initial Document
1.1 04/22/2014 M McFadden Added ICD-10 references and updates
for CCF10735B1-Edifecs
2.0 8/15/2014 TQD DHW validated 8/15/14
2.1 5/19/2015 Doug Greer Semi-annual review performed – made
corrections
3.0 6/8/2015 TQD DHW validated 6/5/15
3.1 12/10/2015 Doug Greer Semi-annual review performed – made
corrections
4.0 1/25/2016 TQD DHW validated changes 1/22/16
4.0 5/25/2016 Cathy Butler Semi-annual review – no changes made
4.0 12/15/2016 Jimmy Phillips Semi-annual review – no changes made
4.1 6/2/2017 Douglas Greer Semi-annual review – Minor corrections
in tables 2-1 and 2-2
5.0 7/25/2017 TQD DHW validate changes 7/25/17
5.0 11/7/2017 Cathy Butler Semi-annual review – no changes made
5.1 6/19/2018 Douglas Greer Semi-annual review – correction to table
in figure 2.2
6.0 09/10/2018 TQD Finalized per 30-day Notification
agreement
6.1 10/05/2018 M Zampierin Removed all Molina references and
replaced with DXC Technology
6.1 11/27/2018 Jimmy Phillips Semi-annual review – no changes made
6.2 01/11/2019 M Zampierin Updated Copyright statement to DXC
6.2 11/27/2019 Cathy Lavacchia Semi-annual review – no changes made
6.3 03/09/2020 Jimmy Phillips Changed for Rebranding CR 58031
7.0 03/30/2020 TQD Finalized per DHW validated changes.
© 2018-2019 DXC Technology Company. All rights reserved. -
http://www.dxc.technology/legal
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
Last Updated: 03/30/2020 Page ii
Table of Contents
1. Companion Guide Purpose ...................................................................................... 1
1.1. Required Information ....................................................................................... 1
1.2. Trading Partner ID .......................................................................................... 1
1.3. Delimiters ...................................................................................................... 2
1.4. Additional Information ..................................................................................... 2
2. 278 Request for Review ......................................................................................... 3
2.1. 278 Response ............................................................................................... 34
Appendix A. ........................................................................................................... 62
Table of Figures
Figure 2-1: Request for Review .................................................................................... 3
Figure 2-2: 278 Response .......................................................................................... 34
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
Last Updated: 03/30/2020 Page 1 of 62
1. Companion Guide Purpose This companion guide documents the transaction type listed below and further defines
situational and required data elements that are used for processing healthcare service
requests for reviews and responses for programs administered by the Idaho Medicaid. This
document is not the complete EDI transaction format specifications.
Please refer to the 5010 Implementation Guide for information not supplied in this
document, such as code lists, definitions, and edits.
Health Care Services Request for Review and Response ASC X12N 278
(005010X217) May 2006
Health Care Services Request for Review and Response ASC X12N 278
(005010X217E1) April 2008
Health Care Services Request for Review and Response ASC X12N 278
(005010X217E2) January 2009
For any questions, or to begin testing, please contact the DXC Technology EDI Helpdesk at
1 (866) 686-4272 option 2 and ask for Technical Support, or e-mail us at
idedisupport@molinahealthcare.com.
1.1. Required Information Data elements, segments, and loops not included in this guide are not used for processing
authorization requests by Idaho Medicaid, but must still be sent if the information is
required for compliance with the ASC X12N version 5010 format.
1.2. Trading Partner ID A trading partner is defined as any entity with which DXC Technology exchanges electronic
data. The term electronic data is not limited to HIPAA X12 transactions. Idaho Medicaid’s
Health PAS system supports the following categories of trading partner:
Provider
Billing Agency
Clearinghouse
Health Plan
DXC Technology will assign trading partner IDs to support the exchange of X12 EDI
transactions for providers, billing agencies and clearinghouses, and other health plans.
All trading partners must be authorized to submit production EDI transactions. Any trading
partner may submit test EDI transactions. The Usage Indicator, element 15 of the
Interchange Control Header (ISA) of an X12 file, indicates if a file is test or production.
Authorization is granted on a per transaction basis. For example, a trading partner may be
certified to submit 837P professional claims but not certified to submit 837I institutional
claim files.
Trading partners must submit three test files of a particular transaction type, with a
minimum of fifteen transactions within each file, and have no failures or rejections in order
to become certified for production. Users will be notified via e-mail and the Trading Partner
Status page of Health PAS-Online when testing for a particular transaction has been
completed.
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
Last Updated: 03/30/2020 Page 2 of 62
Detailed instructions for retrieving and interpreting HIPAA validation acknowledgments may
be found in Appendix A of this document.
To obtain a trading partner ID please visit our website at http://www.idmedicaid.com or
contact us at 1 (866) 686-4272.
1.3. Delimiters Idaho Medicaid does not require the use of specific values for the delimiters used in
electronic transactions. The suggested values are included in the specifications below.
1.4. Additional Information Please refer to the 5010 Implementation Guide for information not supplied in this
document, such as code lists, definitions, and edits.
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
Last Updated: 03/30/2020 Page 3 of 62
2. 278 Request for Review
Figure 2-1: Request for Review
Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req
Des.
Value
Interchange Control Record
HEADER ISA Interchange Control
Header
3 R ISA
Element Separator AN 1 *
ISA01 Authorization Information
Qualifier
ID 2 I01 R 00 – No Authorization Information
Present
Element Separator AN 1 *
ISA02 Authorization Information AN 10 I02 R Space fill
Element Separator AN 1 *
ISA03 Security Information
Qualifier
ID 2 I03 R 00 – No Security Information
Present
Element Separator AN 1 *
ISA04 Security Information AN 10 I04 R Space fill
Element Separator AN 1 *
ISA05 Interchange ID Qualifier ID 2 I05 R ZZ – Mutually Defined
Element Separator AN 1 *
ISA06 Interchange Sender ID AN 15 I06 R DXCMS assigned trading partner ID
Element Separator AN 1 *
ISA07 Interchange ID Qualifier ID 2 I05 R ZZ – Mutually Defined
Element Separator AN 1 *
ISA08 Interchange Receiver ID AN 15 I07 R ID_MMIS_4_DXCMS or
ID_MMIS_4MOLINA
Element Separator AN 1 *
ISA09 Interchange Date DT 6 I08 R YYMMDD
Element Separator AN 1 *
ISA10 Interchange Time TM 4 I09 R HHMM
Element Separator AN 1 *
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
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Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req
Des.
Value
ISA11 Repetition Separator 1 I65 R ^
Element Separator AN 1 *
ISA12 Interchange Version
Number
ID 5 I11 R 00501
Element Separator AN 1 *
ISA13 Interchange Control
Number
N0 9 I12 R Must be identical to the
interchange trailer IEA02 - defined
by sender
Element Separator AN 1 *
ISA14 Acknowledgment
Requested
ID 1 I13 R 0 – No Acknowledgment Requested
1- Interchange Acknowledgement
requested
Element Separator AN 1 *
ISA15 Interchange Usage
Indicator
ID 1 I14 R P – Production Data
T – Test Data
Element Separator AN 1 *
ISA16 Component Element
Separator
1 I15 R :
Segment End B 1 ~
Functional Group Header
GS Functional Group Header 2 R GS
Element Separator AN 1 *
GS01 Functional Identifier Code ID 2 479 R HI
Element Separator AN 1 *
GS02 Application Sender's Code AN 2/15 142 R DXCMS Assigned Trading Partner
ID
Element Separator AN 1 *
GS03 Application Receiver's
Code
AN 2/15 124 R ID_MMIS_4_DXCMS or
ID_MMIS_4MOLINA
Element Separator AN 1 *
GS04 Date DT 8 373 R CCYYMMDD
Element Separator AN 1 *
GS05 Time TM 4/8 337 R HHMM
Element Separator AN 1 *
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
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Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req
Des.
Value
GS06 Group Control Number N0 1/9 28 R Assigned by Sender
Element Separator AN 1 *
GS07 Responsible Agency Code ID 1/2 455 R X – Accredited Standards
Committee X12
Element Separator AN 1 *
GS08 Version / Release Code AN 1/12 480 R 005010X217
Segment End B 1 ~
Transaction Set Header
ST Transaction Set Header 2 R ST
Element Separator AN 1 *
ST01 Transaction Set Identifier
Code
ID 3 143 R 278 – Health Care Services Review
Information
Element Separator AN 1 *
ST02 Transaction Set Control
Number
AN 4/9 329 R Sequential number assigned by
sender ST and SE must be equal
Element Separator AN 1 *
ST03 Implementation
Convention Reference
AN 1/35 1705 R 005010X217
Segment End B 1 ~
Beginning of Hierarchical Transaction
BHT Beginning Hierarchical
Transaction Segment
ID 3 R BHT
Element Separator AN 1 *
BHT01 Hierarchical Structure
Code
ID 4 1005 R 0007 – Information Source,
Information Receiver, Subscriber,
Dependent, Provider of Service,
Services
Element Separator AN 1 *
BHT02 Transaction Set Purpose
Code
ID 2 353 R 01 = Cancellation
13 – Request
Element Separator AN 1 *
BHT03 Reference identification AN 1/50 127 R Submitter Transaction Identifier.
Element Separator AN 1 *
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
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Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req
Des.
Value
BHT04 Date DT 8 373 R CCYYMMDD
- Transaction Set Creation Date
Element Separator AN 1 *
BHT05 Time TM 4/8 337 R HHMM
- Transaction Set Creation Time
Segment End B 1 ~
UMO (Loop 2000A)
2000A HL Hierarchical Level
Segment
ID 2 R HL
Element Separator AN 1 *
HL01 Hierarchical ID Number AN 1/12 628 R 1
Element Separator AN 1 *
Element Separator AN 1 *
HL03 Hierarchical Level Code ID 1/2 735 R 20 – Information Source
Element Separator AN 1 *
HL04 Hierarchical Child Code ID 1 736 R 1 – Additional Subordinate HL Data
Segment in This Hierarchical
Structure.
Segment End B 1 ~
2010A NM1 Individual or
Organizational Name
ID 3 R NM1
Element Separator AN 1 *
NM101 Entity Identifier Code ID 2/3 98 R X3 - UMO
Element Separator AN 1 *
NM102 Entity Type Qualifier ID 1 1065 R 2 – Non-Person Entity
Element Separator AN 1 *
NM103 Name Last or
Organization Name
AN 1/60 1035 R IDAHO MEDICAID
Element Separator AN 1 *
NM104 Name First AN 1/25 1036 S
Element Separator AN 1 *
NM105 Name Middle AN 1/25 1037
Element Separator AN 1 *
Element Separator AN 1 *
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
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Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req
Des.
Value
NM107 Name Suffix AN 1/10 1039 S
Element Separator AN 1 *
NM108 Identification Code
Qualifier
ID 1/2 66 R PI – Payor Identification
Element Separator AN 1 *
NM109 Identification Code AN 2/80 67 R ID_MMIS_4MOLINA
Segment End B 1 ~
Requester (Loop 2000B)
2000B HL Hierarchical Level
Segment
ID 2 R HL
Element Separator AN 1 *
HL01 Hierarchical ID Number AN 1/12 628 R 2
Element Separator AN 1 *
HL02 Hierarchical Parent ID
Number
AN 1/12 734 R 1
Element Separator AN 1 *
HL03 Hierarchical Level Code ID 1/2 735 R 21 – Information Receiver
Element Separator AN 1 *
HL04 Hierarchical Child Code ID 1 736 R 1 – Additional Subordinate HL Data
Segment in This Hierarchical
Structure.
Segment End B 1 ~
2010B NM1 Individual or
Organizational Name
ID 3 R NM1
Element Separator AN 1 *
NM101 Entity Identifier Code ID 2/3 98 R 1P – Provider, FA – Facility
Element Separator AN 1 *
NM102 Entity Type Qualifier ID 1 1065 R 1 – Person 2 – Non Person Entity
Element Separator AN 1 *
NM103 Name Last or
Organization Name
AN 1/60 1035 R
Element Separator AN 1 *
NM104 Name First AN 1/35 1036 S Required if NM102=1 (Person)
Element Separator AN 1 *
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
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Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req
Des.
Value
NM105 Name Middle AN 1/25 1037 S
Element Separator AN 1 *
Element Separator AN 1 *
NM107 Name Suffix AN 1/10 1039 S
Element Separator AN 1 *
NM108 Identification Code
Qualifier
ID 1/2 66 R 24=Employer’s Identification
Number (for Atypical Providers
Only)
XX= National Provider Identifier
34 = SSN (Atypical providers
without EIN)
Element Separator AN 1 *
NM109 Identification Code AN 2/80 67 R Provider NPI, Idaho EIN, or SSN
Segment End B 1 ~
2010B REF Reference Identification ID 3 S REF
Element Separator AN 1 *
REF01 Reference Identification
Qualifier
ID 2/3 128 R N5
Element Separator AN 1 *
REF02 Reference Identification AN 1/50 127 R Medicaid assigned provider ID for
the Requesting Provider – for
Atypical providers only
Segment End B 1 ~
Subscriber (Loop 2000C)
2000C HL Hierarchical Level
Segment
ID 2 R HL
Element Separator AN 1 *
HL01 Hierarchical ID Number AN 1/12 628 R 3
Element Separator AN 1 *
HL02 Hierarchical Parent ID
Number
AN 1/12 734 R 2
Element Separator AN 1 *
HL03 Hierarchical Level Code ID 1/2 735 R 22=Subscriber
Element Separator AN 1 *
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
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Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req
Des.
Value
HL04 Hierarchical Child Code ID 1 736 R 1
Segment End B 1 ~
2010C NM1 Individual or
Organizational Name
ID 3 R NM1
Element Separator AN 1 *
NM101 Entity Identifier Code ID 2/3 98 R IL = Insured or Provider
Element Separator AN 1 *
NM102 Entity Type Qualifier ID 1 1065 R 1 = Person
Element Separator AN 1 *
NM103 Name Last or
Organization Name
AN 1/60 1035 S
Element Separator AN 1 *
NM104 Name First AN 1/35 1036 S
Element Separator AN 1 *
NM105 Name Middle AN 1/25 1037 S
Element Separator AN 1 *
NM106 Name Prefix AN 1/10 1038 S
Element Separator AN 1 *
NM107 Name Suffix AN 1/10 1039 S
Element Separator AN 1 *
NM108 Identification Code
Qualifier
ID 1/2 66 R MI = Member Identification
Number
Element Separator AN 1 *
NM109 Identification Code AN 7/10 67 R Enter the Idaho Medicaid member’s
7 or 10 digit identification number
as it appears on their ID card
Segment End B 1 ~
2010C DMG Demographic Information ID 3 S DMG
Element Separator AN 1 *
DMG01 Date Time Period Format
Qualifier
ID 2/3 1250 R D8
Element Separator AN 1 *
DMG02 Date Time Period AN 1/35 1251 R Patient Date of Birth
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
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Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req
Des.
Value
Element Separator AN 1 *
DMG03 Gender Code ID 1 1068 S Patient Gender
Segment End B 1 ~
Service Provider (Loop 2000E)
2000E HL Hierarchical Level
Segment
ID 2 R HL
Element Separator AN 1 *
HL01 Hierarchical ID Number AN 1/12 628 R 4
Element Separator AN 1 *
HL02 Hierarchical Parent ID
Number
AN 1/12 734 R 3
Element Separator AN 1 *
HL03 Hierarchical Level Code ID 1/2 735 R EV=Event
Element Separator AN 1 *
HL04 Hierarchical Child Code ID 1/1 736 R 0 = No Subordinate HL Segment
1= Additional Subordinate HL Data
Segment
Segment End B 1 ~
2000E TRN Patient Event Tracking
Number Segment
ID 3 S TRN
Element Separator AN 1 *
TRN01 Trace Type Code ID 1/2 481 R 1
Element Separator AN 1 *
TRN02 Reference Identification AN 1/50 127 R
Element Separator AN 1 *
TRN03 Originating Company
Identifier
AN 10 509 R
Element Separator AN 1 *
TRN04 Reference Identification AN 1/50 127 S
Segment End B 1 ~
2000E UM Health Care Services
Review Information
ID 2 R UM
Element Separator AN 1 *
UM01 Request Category Code ID 1/2 1525 R AR=Admission Review
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
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Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req
Des.
Value
HS=Health Services Review
Element Separator AN 1 *
UM02 Certification Type Code ID 1/1 1322 R I = Initial
3 = Cancel
4 = Extension
Element Separator AN 1 *
UM03 Service Type Code ID 1/2 1365 R For Prior Authorizations see UM03
Service Type PA Crosswalk in this
guide
Element Separator AN 1 *
UM04 Health Care Service
Location Information
ID C023 S
UM04-1 Facility Code Value AN 1/2 1331 R
Component Element
Separator
1 :
UM04-2 Facility Code Qualifier ID 1/2 1332 R
Element Separator AN 1 *
UM05 Related Causes
Information
ID C024 S Required when the patient’s
condition is accident or
employment related
UM05-1 Related-Causes Code ID 2/3 1362 R Always use this data element if the
related cause is an auto accident
Component Element
Separator
1 :
UM05-2 Related-Causes Code ID 2/3 1362 S
Component Element
Separator
1 :
UM05-3 Related-Causes Code ID 2/3 1362 S
Component Element
Separator
1 :
UM05-4 State or Province Code ID 2/2 156 S Required on review requests if
UM05-1=AA, if the accident
occurred out of the service
provider's state
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
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Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req
Des.
Value
Component Element
Separator
1 :
UM05-5 Country Code ID 2/3 26 S Required if automobile accident
occurred out of the U.S.
Element Separator AN 1 *
UM06 Level of Service Code ID 1/3 1338 S Recommended if the service
requested would not be authorized
unless the patient's condition is
Emergency or Urgent
Element Separator AN 1 *
UM07 Current Health Condition
Code
ID 1 1213 S
Element Separator AN 1 *
UM08 Prognosis Code ID 1 923 S
Element Separator AN 1 *
UM09 Release of Information
Code
ID 1 1363 S
Element Separator AN 1 *
UM10 Delay Reason Code ID 1/2 1514 S Required if the request is not
submitted within the normal
timeframe of the UMO
Segment End B 1 ~
2000E REF Reference Identification ID 3 S REF
Element Separator AN 1 *
REF01 Reference Identification
Qualifier
ID 2/3 128 R BB=Authorization Number
Element Separator AN 1 *
REF02 Reference Identification AN 1/50 127 R Required if UM02 segment under
2000E Health Care Services review
Information equals a 3, indicating
action on previous authorization
Segment End B 1 ~
2000E DTP Date or Time or Period ID 3 S DTP
Element Separator AN 1 *
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
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Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req
Des.
Value
DTP01 Date/Time Qualifier ID 3 374 R 439 = Accident
Element Separator AN 1 *
DTP02 Date Time Period Format
Qualifier
ID 2/3 1250 R D8 = date expressed in format
CCYYMMDD
Element Separator AN 1 *
DTP03 Date Time Period AN 1/35 1251 R format = CCYYMMDD
Segment End B 1 ~
2000E DTP Date or Time or Period ID 3 S DTP
Element Separator AN 1 *
DTP01 Date/Time Qualifier ID 3 374 R 484 = Last Menstrual Period
Element Separator AN 1 *
DTP02 Date Time Period Format
Qualifier
ID 2/3 1250 R D8 = date expressed in format
CCYYMMDD
Element Separator AN 1 *
DTP03 Date Time Period AN 1/35 1251 R format = CCYYMMDD
Segment End B 1 ~
2000E DTP Date or Time or Period ID 3 S DTP
Element Separator AN 1 *
DTP01 Date/Time Qualifier ID 3 374 R ABC = Estimated Date of Birth
Element Separator AN 1 *
DTP02 Date Time Period Format
Qualifier
ID 2/3 1250 R D8 = date expressed in format
CCYYMMDD
Element Separator AN 1 *
DTP03 Date Time Period AN 1/35 1251 R format = CCYYMMDD
Segment End B 1 ~
2000E DTP Date or Time or Period ID 3 S DTP
Element Separator AN 1 *
DTP01 Date/Time Qualifier ID 3 374 R 431 = Onset of Current Symptoms
or Illness
Element Separator AN 1 *
DTP02 Date Time Period Format
Qualifier
ID 2/3 1250 R D8 = date expressed in format
CCYYMMDD
Element Separator AN 1 *
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
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Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req
Des.
Value
DTP03 Date Time Period AN 1/35 1251 R format = CCYYMMDD
Segment End B 1 ~
2000E DTP Date or Time or Period ID 3 S DTP
Element Separator AN 1 *
DTP01 Date/Time Qualifier ID 3 374 R AAH = Event
Element Separator AN 1 *
DTP02 Date Time Period Format
Qualifier
ID 2/3 1250 R D8 = date expressed in format
CCYYMMDD
RD8 = date expressed in format
CCYYMMDD-CCYYMMDD
Element Separator AN 1 *
DTP03 Date Time Period AN 1/35 1251 R format = CCYYMMDD if DTP02 =
D8
format = CCYYMMDD-CCYYMMDD
if DTP02 = RD8
Segment End B 1 ~
2000E DTP Date or Time or Period ID 3 S DTP
Element Separator AN 1 *
DTP01 Date/Time Qualifier ID 3 374 R 435 =Admission
Element Separator AN 1 *
DTP02 Date Time Period Format
Qualifier
ID 2/3 1250 R D8 = date expressed in format
CCYYMMDD
RD8 = date expressed in format
CCYYMMDD-CCYYMMDD
Element Separator AN 1 *
DTP03 Date Time Period AN 1/35 1251 R format = CCYYMMDD if DTP02 =
D8
format = CCYYMMDD-CCYYMMDD
if DTP02 = RD8
Segment End B 1 ~
2000E DTP Date or Time or Period ID 3 S DTP
Element Separator AN 1 *
DTP01 Date/Time Qualifier ID 3 374 R 096 = Discharge
Element Separator AN 1 *
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
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Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req
Des.
Value
DTP02 Date Time Period Format
Qualifier
ID 2/3 1250 R D8 = date expressed in format
CCYYMMDD
Element Separator AN 1 *
DTP03 Date Time Period AN 1/35 1251 R format = CCYYMMDD
Segment End B 1 ~
2000E HI Health Care Information
Codes
ID 2 S HI
Element Separator AN 1 *
HI01 Health Care Code
Information – Alias
Diagnosis 1
ID 4 C022 S
HI01-1 Code List Qualifier Code ID 1/3 1270 R BK (ICD-9) – Principal Diagnosis
ABK (ICD-10) – Principal Diagnosis
BF (ICD-9) - Diagnosis
ABF (ICD-10) - Diagnosis
BJ (ICD-9) – Admitting Diagnosis
ABJ (ICD-10) – Admitting
Diagnosis
Component Element
Separator
1 :
HI01-2 Industry Code AN 1/30 1271 R Diagnosis Code
Component Element
Separator
1 :
HI01-3 Date Time Period Format
Qualifier
ID 2/3 1250 S D8 = date expressed in format
CCYYMMDD
Component Element
Separator
1 :
HI01-4 Date Time Period AN 1/35 1251 S Diagnosis Date. Format date
CCYYMMDD
Element Separator AN 1 *
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
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Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req
Des.
Value
HI02 Health Care Code
Information – Alias
Diagnosis 2
ID 4 C022 S
HI02-1 Code List Qualifier Code ID 1/3 1270 R BF (ICD-9) - Diagnosis
ABF (ICD-10) - Diagnosis
BJ (ICD-9) – Admitting Diagnosis
ABJ (ICD-10) – Admitting
Diagnosis
Component Element
Separator
1 :
HI02-2 Industry Code AN 1/30 1271 R Diagnosis Code
Component Element
Separator
1 :
HI02-3 Date Time Period Format
Qualifier
ID 2/3 1250 S D8 = date expressed in format
CCYYMMDD
Component Element
Separator
1 :
HI02-4 Date Time Period AN 1/35 1251 S Diagnosis Date. Format date
CCYYMMDD
Element Separator AN 1 *
HI03 Health Care Code
Information – Alias
Diagnosis 3
ID 4 C022 S
HI03-1 Code List Qualifier Code ID 1/3 1270 R BF (ICD-9) - Diagnosis
ABF (ICD-10) - Diagnosis
Component Element
Separator
1 :
HI03-2 Industry Code AN 1/30 1271 R Diagnosis Code
Component Element
Separator
1 :
HI03-3 Date Time Period Format
Qualifier
ID 2/3 1250 S D8 = date expressed in format
CCYYMMDD
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Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req
Des.
Value
Component Element
Separator
1 :
HI03-4 Date Time Period AN 1/35 1251 S Diagnosis Date. Format date
CCYYMMDD
Element Separator AN 1 *
Note: Can be up to 10 HI0x-1 thru
HI0x-4 BF/ABF (Other Diagnosis
Code) elements separated by *
Segment End B 1 ~
2000E HSD Health Care Delivery
Services
ID 3 S HSD
Element Separator AN 1 *
HSD01 Quantity Qualifier ID 2 673 S
Element Separator AN 1 *
HSD02 Quantity R 1/15 380 S
Element Separator AN 1 *
HSD03 Unit or Basis for
Measurement Code
ID 2 355 S
Element Separator AN 1 *
HSD04 Sample Selection Modulus R 1/6 1167 S
Element Separator AN 1 *
HSD05 Time Period Qualifier ID 1/2 615 S
Element Separator AN 1 *
HSD06 Number of Periods N0 1/3 616 S
Element Separator AN 1 *
HSD07 Ship/Delivery or Calendar
Pattern Code
ID 1/2 678 S
Element Separator AN 1 *
HSD08 Ship/Delivery Pattern
Time Code
ID 1 679 S
Segment End B 1 ~
2000E CRC Conditions Indicator ID 3 S CRC
Element Separator AN 1 *
CRC01 Code Category ID 2 1136 R 07 = Ambulance Certification
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
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Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req
Des.
Value
Element Separator AN 1 *
CRC02 Yes/No Condition or
Response Code
ID 1 1073 R
Element Separator AN 1 *
CRC03 Condition Indicator ID 2/3 1321 R
Element Separator AN 1 *
CRC04 Condition Indicator ID 2/3 1321 S
Element Separator AN 1 *
CRC05 Condition Indicator ID 2/3 1321 S
Element Separator AN 1 *
CRC06 Condition Indicator ID 2/3 1321 S
Element Separator AN 1 *
CRC07 Condition Indicator ID 2/3 1321 S
Segment End B 1 ~
2000E CRC Conditions Indicator ID 3 S CRC
Element Separator AN 1 *
CRC01 Code Category ID 2 1136 R 08 = Chiropractic Certification
Element Separator AN 1 *
CRC02 Yes/No Condition or
Response Code
ID 1 1073 R
Element Separator AN 1 *
CRC03 Condition Indicator ID 2/3 1321 R
Element Separator AN 1 *
CRC04 Condition Indicator ID 2/3 1321 S
Element Separator AN 1 *
CRC05 Condition Indicator ID 2/3 1321 S
Element Separator AN 1 *
CRC06 Condition Indicator ID 2/3 1321 S
Element Separator AN 1 *
CRC07 Condition Indicator ID 2/3 1321 S
Segment End B 1 ~
2000E CRC Conditions Indicator ID 3 S CRC
Element Separator AN 1 *
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
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Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req
Des.
Value
CRC01 Code Category ID 2 1136 R 09 = Durable Medical Equipment
Certification
Element Separator AN 1 *
CRC02 Yes/No Condition or
Response Code
ID 1 1073 R
Element Separator AN 1 *
CRC03 Condition Indicator ID 2/3 1321 R
Element Separator AN 1 *
CRC04 Condition Indicator ID 2/3 1321 S
Element Separator AN 1 *
CRC05 Condition Indicator ID 2/3 1321 S
Element Separator AN 1 *
CRC06 Condition Indicator ID 2/3 1321 S
Element Separator AN 1 *
CRC07 Condition Indicator ID 2/3 1321 S
Segment End B 1 ~
2000E CRC Conditions Indicator ID 3 S CRC
Element Separator AN 1 *
CRC01 Code Category ID 2 1136 R 11 = Oxygen Therapy Certification
Element Separator AN 1 *
CRC02 Yes/No Condition or
Response Code
ID 1 1073 R
Element Separator AN 1 *
CRC03 Condition Indicator ID 2/3 1321 R
Element Separator AN 1 *
CRC04 Condition Indicator ID 2/3 1321 S
Element Separator AN 1 *
CRC05 Condition Indicator ID 2/3 1321 S
Element Separator AN 1 *
CRC06 Condition Indicator ID 2/3 1321 S
Element Separator AN 1 *
CRC07 Condition Indicator ID 2/3 1321 S
Segment End B 1 ~
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
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Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req
Des.
Value
2000E CRC Conditions Indicator ID 3 S CRC
Element Separator AN 1 *
CRC01 Code Category ID 2 1136 R 75 = Functional Limitations
Element Separator AN 1 *
CRC02 Yes/No Condition or
Response Code
ID 1 1073 R
Element Separator AN 1 *
CRC03 Condition Indicator ID 2/3 1321 R
Element Separator AN 1 *
CRC04 Condition Indicator ID 2/3 1321 S
Element Separator AN 1 *
CRC05 Condition Indicator ID 2/3 1321 S
Element Separator AN 1 *
CRC06 Condition Indicator ID 2/3 1321 S
Element Separator AN 1 *
CRC07 Condition Indicator ID 2/3 1321 S
Segment End B 1 ~
2000E CRC Conditions Indicator ID 3 S CRC
Element Separator AN 1 *
CRC01 Code Category ID 2 1136 R 76 = Activities Permitted
Element Separator AN 1 *
CRC02 Yes/No Condition or
Response Code
ID 1 1073 R
Element Separator AN 1 *
CRC03 Condition Indicator ID 2/3 1321 R
Element Separator AN 1 *
CRC04 Condition Indicator ID 2/3 1321 S
Element Separator AN 1 *
CRC05 Condition Indicator ID 2/3 1321 S
Element Separator AN 1 *
CRC06 Condition Indicator ID 2/3 1321 S
Element Separator AN 1 *
CRC07 Condition Indicator ID 2/3 1321 S
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
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Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req
Des.
Value
Segment End B 1 ~
2000E CRC Conditions Indicator ID 3 S CRC
Element Separator AN 1 *
CRC01 Code Category ID 2 1136 R 77 = Mental Status
Element Separator AN 1 *
CRC02 Yes/No Condition or
Response Code
ID 1 1073 R
Element Separator AN 1 *
CRC03 Condition Indicator ID 2/3 1321 R
Element Separator AN 1 *
CRC04 Condition Indicator ID 2/3 1321 S
Element Separator AN 1 *
CRC05 Condition Indicator ID 2/3 1321 S
Element Separator AN 1 *
CRC06 Condition Indicator ID 2/3 1321 S
Element Separator AN 1 *
CRC07 Condition Indicator ID 2/3 1321 S
Segment End B 1 ~
2000E CL1 Claim Codes ID 3 S CL1 Required when UM01 = AR
Element Separator AN 1 *
CL101 Admission Type Code ID 1 1315 S
Element Separator AN 1 *
CL102 Admission Source Code R 1 1314 S
Element Separator AN 1 *
CL103 Patient Status Code ID ½ 1352 S
Element Separator AN 1 *
CL104 Nursing Home Residential
Status Code
ID 1 1345 S
Segment End B 1 ~
2000E CR1 Ambulance Certification ID 3 S CR1
Note: Loop 2010EB is
required when 2000E/CR1
is used
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
Last Updated: 03/30/2020 Page 22 of 62
Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req
Des.
Value
Element Separator AN 1 *
CR101 Unit or Basis for
Measurement Code
ID 2 355 S
Element Separator AN 1 *
CR102 Weight R 1/10 81 S
Element Separator AN 1 *
CR103 Ambulance Transport
Code
ID 1 1316 R
Element Separator AN 1 *
CR104 Ambulance Transport
Reason Code
ID 1 1317 R
Element Separator AN 1 *
CR105 Unit or Basis for
Measurement Code
ID 2 355 S
Element Separator AN 1 *
CR106 Quantity R 1/15 380 S
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
CR109 Description AN 1/80 352 S Required if needed when CR103 =
X. Otherwise Not Used.
Element Separator AN 1 *
CR110 Description AN 1/80 352 S
Segment End B 1 ~
2000E CR2 Chiropractic Certification ID 3 S CR2
Element Separator AN 1 *
CR201 Count N0 1/9 609 S
Element Separator AN 1 *
CR202 Quantity R 1/15 380 S
Element Separator AN 1 *
CR203 Subluxation Level Code ID 2/3 1367 S
Element Separator AN 1 *
CR204 Subluxation Level Code ID 2/3 1367 S
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
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Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req
Des.
Value
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
CR208 Nature of Condition Code ID 1 1342 R
Element Separator AN 1 *
CR209 Yes/No Condition or
Response Code
ID 1 1073 R
Element Separator AN 1 *
CR210 Description AN 1/80 352 S
Element Separator AN 1 *
CR211 Description AN 1/80 352 S
Note: CR211 should not
be used when element
CR210 is not used
Element Separator AN 1 *
CR212 Yes/No Condition or
Response Code
ID 1 1073 R
Segment End B 1 ~
2000E CR6 Home Health Care
Certification
ID 3 S CR6
Element Separator AN 1 *
CR601 Prognosis Code ID 1 923 R
Element Separator AN 1 *
CR602 Date DT 8 373 R format CCYYMMDD
Element Separator AN 1 *
CR603 Date Time Period Format
Qualifier
ID 2/3 1250 S RD8
Element Separator AN 1 *
CR604 Date Time Period AN 1/35 1251 S format CCYYMMDD-CCYYMMDD
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
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Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req
Des.
Value
CR607 Yes/No Condition or
Response Code
ID 1 1073 R W
Element Separator AN 1 *
CR608 Certification Type Code ID 1 1322 R
Element Separator AN 1 *
CR609 Date DT 8 373 S
Element Separator AN 1 *
CR610 Product/Service ID
Qualifier
ID 2 235 S
Element Separator AN 1 *
CR611 Medical Code Value AN 1/15 1137 S
Element Separator AN 1 *
CR612 Date DT 8 373 S
Element Separator AN 1 *
CR613 Date DT 8 373 S
Element Separator AN 1 *
CR614 Date DT 8 373 S
Element Separator AN 1 *
CR615 Date Time Period Format
Qualifier
ID 2/3 1250 S RD8 Required if the patient had a
recent inpatient stay
Element Separator AN 1 *
CR616 Date Time Period AN 1/35 1251 S format CCYYMMDD-CCYYMMDD
Required if the patient had a recent
inpatient stay
Element Separator AN 1 *
CR617 Patient Location Code ID 1 1384 S Required if the patient had a recent
inpatient stay
Segment End B 1 ~
2010EA NM1 Individual or
Organizational Name
ID 3 R NM1
Element Separator AN 1 *
NM101 Entity Identifier Code ID 2/3 98 R
Element Separator AN 1 *
NM102 Entity Type Qualifier ID 1 1065 R 1=Person, 2=Non-Person Entity
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
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Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req
Des.
Value
Element Separator AN 1 *
NM103 Name Last or
Organization Name
AN 1/60 1035 S
Element Separator AN 1 *
NM104 Name First AN 1/35 1036 S Required if NM102=1 & NM103 is
present
Element Separator AN 1 *
NM105 Name Middle AN 1/25 1037 S Only used if NM102=1
Element Separator AN 1 *
NM106 Name Prefix AN 1/10 1038 S
Element Separator AN 1 *
NM107 Name Suffix AN 1/10 1039 S
Element Separator AN 1 *
NM108 Identification Code
Qualifier
ID 1/2 66 S 24=Employer’s Identification
Number (for atypical providers
only)
XX= National Provider Identifier
Element Separator AN 1 *
NM109 Identification Code AN 2/80 67 S Enter NPI or if provider is atypical
enter Employer Identification
Number
Segment End B 1 ~
2010EA REF Reference Information ID 3 S REF
Element Separator AN 1 *
REF01 Reference Identification
Qualifier
ID 2/3 128 R N5 = Provider Plan Network
Identifier
Element Separator AN 1 *
REF02 Reference Identification AN 1/50 127 R Used for atypical providers only, to
enter their assigned Provider ID
Segment End B 1 ~
2010EB NM1 Individual or
Organizational Name
ID 3 R NM1
Element Separator AN 1 *
NM101 Entity Identifier Code ID 2/3 98 R
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Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req
Des.
Value
Element Separator AN 1 *
NM102 Entity Type Qualifier ID 1 1065 R 2 = Non-Person Entity
Element Separator AN 1 *
NM103 Name Last or
Organization Name
AN 1/60 1035 S
Segment End B 1 ~
2010EC NM1 Individual or
Organizational Name
ID 3 R NM1
Element Separator AN 1 *
NM101 Entity Identifier Code ID 2/3 98 R
Element Separator AN 1 *
NM102 Entity Type Qualifier ID 1 1065 R 2 = Non-Person Entity
Element Separator AN 1 *
NM103 Name Last or
Organization Name
AN 1/60 1035 S
Segment End B 1 ~
2010EC REF Reference Information ID 3 S REF
Element Separator AN 1 *
REF01 Reference Identification
Qualifier
ID 2/3 128 R ZZ – Mutually Defined
Element Separator AN 1 *
REF02 Reference Identification AN 1/50 127 R
Element Separator AN 1 *
Element Separator AN 1 *
REF04 Reference Identifier O C040 S
REF04-1 Reference Identification
Qualifier
ID 2/3 128 R ZZ – Mutually Defined
Element Separator AN 1 :
REF04-2 Reference Identification AN 1/50 127 R
Element Separator AN 1 :
REF04-3 Reference Identification
Qualifier
ID 2/3 128 S ZZ – Mutually Defined
Element Separator AN 1 :
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
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Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req
Des.
Value
REF04-4 Reference Identification AN 1/50 127 S
Element Separator AN 1 :
REF04-5 Reference Identification
Qualifier
ID 2/3 128 S ZZ – Mutually Defined
Element Separator AN 1 :
REF04-6 Reference Identification AN 1/50 127 S
Segment End B 1 ~
2000EC DTP Date or Time or Period ID 3 R DTP
Element Separator AN 1 *
DTP01 Date/Time Qualifier ID 3 374 R 598 = Rejected
Element Separator AN 1 *
DTP02 Date Time Period Format
Qualifier
ID 2/3 1250 R D8
Element Separator AN 1 *
DTP03 Date Time Period AN 1/35 1251 R format = CCYYMMDD
Segment End B 1 ~
Service (Loop 2000F)
2000F HL Hierarchical Level
Segment
ID 2 R HL
Element Separator AN 1 *
HL01 Hierarchical ID Number AN 1/12 628 R 5
Element Separator AN 1 *
HL02 Hierarchical Parent ID
Number
AN 1/12 734 R 4
Element Separator AN 1 *
HL03 Hierarchical Level Code ID 1/2 735 R SS
Element Separator AN 1 *
HL04 Hierarchical Child Code ID 1/1 736 R 0
Segment End B 1 ~
2000F DTP Date or Time or Period ID 3 S DTP required if SV2 is used
Element Separator AN 1 *
DTP01 Date/Time Qualifier ID 3 374 R 472 – Service
Element Separator AN 1 *
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
Last Updated: 03/30/2020 Page 28 of 62
Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req
Des.
Value
DTP02 Date Time Period Qualifier ID 2/3 1250 R D8 – Date Format CCYYMMDD
RD8 – Date Format CCYYMMDD-
CCYYMMDD
Element Separator AN 1 *
DTP03 Date Time Period AN 1/35 1251 R CCYYMMDD if DTP02 = D8
CCYYMMDD-CCYYMMDD if DTP02 =
RD8
Segment End B 1 ~
2000F SV1 Professional Service ID 3 S SV1
Element Separator AN 1 *
SV101 Composite Medical
Procedure Identifier
C003 R
SV101-1 Product/Service ID
Qualifier
ID 2 235 R HC = HCPCS Code
Element Separator AN 1 :
SV101-2 Product/Service ID AN 1/48 234 R
Element Separator AN 1 :
SV101-3 Procedure Modifier AN 2 1339 S
Element Separator AN 1 :
SV101-4 Procedure Modifier AN 2 1339 S
Element Separator AN 1 :
SV101-5 Procedure Modifier AN 2 1339 S
Element Separator AN 1 :
SV101-6 Procedure Modifier AN 2 1339 S
Element Separator AN 1 :
SV101-7 Description AN 1/80 352 S
Element Separator AN 1 :
SV101-8 Product/Service ID AN 1/48 234 S
Element Separator AN 1 *
SV102 Monetary Amount R 1/18 782 S
Element Separator AN 1 *
SV103 Unit or Basis for
Measurement Code
ID 2 355 S UN = Unit
Element Separator AN 1 *
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
Last Updated: 03/30/2020 Page 29 of 62
Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req
Des.
Value
SV104 Quantity R 1/15 380 S
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
SV107 Composite Diagnosis
Code Pointer
C004 S
SV107-1 Diagnosis Code Pointer N0 1/2 1328 R
Element Separator AN 1 :
SV107-2 Diagnosis Code Pointer N0 1/2 1328 S
Element Separator AN 1 :
SV107-3 Diagnosis Code Pointer N0 1/2 1328 S
Element Separator AN 1 :
SV107-4 Diagnosis Code Pointer N0 1/2 1328 S
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
SV111 Yes/No Condition or
Response Code
ID 1 1073 S N = No
Y = Yes
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
SV120 Level of Care Code ID 1 1337 S
Segment End B 1 ~
2000F SV2 Institutional Service ID 3 S SV2
Element Separator AN 1 *
SV201 Product/Service ID AN 1/48 234 S
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
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Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req
Des.
Value
Element Separator AN 1 *
SV202 Composite Medical
Procedure Identifier
C003 S
SV202-1 Product/Service ID
Qualifier
ID 2 235 R HC = HCPCS Code
Element Separator AN 1 :
SV202-2 Product/Service ID AN 1/48 234 R
Element Separator AN 1 :
SV202-3 Procedure Modifier AN 2 1339 S
Element Separator AN 1 :
SV202-4 Procedure Modifier AN 2 1339 S
Element Separator AN 1 :
SV202-5 Procedure Modifier AN 2 1339 S
Element Separator AN 1 :
SV202-6 Procedure Modifier AN 2 1339 S
Element Separator AN 1 :
SV202-7 Description AN 1/80 352 S
Element Separator AN 1 :
SV202-8 Product/Service ID AN 1/48 234 S
Element Separator AN 1 *
SV203 Monetary Amount R 1/18 782 S
Element Separator AN 1 *
SV204 Unit or Basis for
Measurement Code
ID 2 355 S DA =Days
UN = Unit
Element Separator AN 1 *
SV205 Quantity R 1/15 380 S
Element Separator AN 1 *
SV206 Unit Rate R 1/10 1371 S
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
SV209 Nursing Home Residential
Status Code
ID 1 1345 S
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
Last Updated: 03/30/2020 Page 31 of 62
Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req
Des.
Value
Element Separator AN 1 *
SV210 Level of Care Code ID 1 1337 S
Segment End B 1 ~
2000F SV3 Dental Service ID 3 S SV3
Element Separator AN 1 *
SV301 Composite Medical
Procedure Identifier
C003 R
SV301-1 Product/Service ID
Qualifier
ID 2 235 R AD = American Dental Association
Codes
Element Separator AN 1 :
SV301-2 Product/Service ID AN 1/48 234 R
Element Separator AN 1 :
SV301-3 Procedure Modifier AN 2 1339 S
Element Separator AN 1 :
SV301-4 Procedure Modifier AN 2 1339 S
Element Separator AN 1 :
SV301-5 Procedure Modifier AN 2 1339 S
Element Separator AN 1 :
SV301-6 Procedure Modifier AN 2 1339 S
Element Separator AN 1 :
SV301-7 Description AN 1/80 352 S
Element Separator AN 1 :
SV301-8 Product/Service ID AN 1/48 234 S
Element Separator AN 1 *
SV302 Monetary Amount R 1/18 782 S
Element Separator AN 1 *
Element Separator AN 1 *
SV304 Oral Cavity Designation C006 S
Element Separator AN 1 :
SV304-1 Oral Cavity Designation
Code
ID 1/3 1361 R
Element Separator AN 1 :
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
Last Updated: 03/30/2020 Page 32 of 62
Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req
Des.
Value
SV304-2 Oral Cavity Designation
Code
ID 1/3 1361 S
Element Separator AN 1 :
SV304-3 Oral Cavity Designation
Code
ID 1/3 1361 S
Element Separator AN 1 :
SV304-4 Oral Cavity Designation
Code
ID 1/3 1361 S
Element Separator AN 1 :
SV304-5 Oral Cavity Designation
Code
ID 1/3 1361 S
Element Separator AN 1 *
SV305 Prosthesis, Crown or Inlay
Code
ID 1 1358 S I = Initial Placement
R = Replacement
Element Separator AN 1 *
SV306 Quantity R 1/15 380 R
Element Separator AN 1 *
SV307 Description AN 1/80 352 S
Segment End B 1 ~
2000F TOO Tooth Identification ID 3 S TOO
Element Separator AN 1 *
TOO01 Code List Qualifier Code ID 1/3 1270 R JP = Universal National Tooth
Designation System
Element Separator AN 1 *
TOO02 Industry Code AN 1/30 1271 R
Element Separator AN 1 *
TOO03 Tooth Surface C005 S
TOO03-1 Tooth Surface Code ID 1/2 1369 R
Element Separator AN 1 :
TOO03-2 Tooth Surface Code ID ½ 1369 S
Element Separator AN 1 :
TOO03-3 Tooth Surface Code ID 1/2 1369 S
Element Separator AN 1 :
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
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Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req
Des.
Value
TOO03-4 Tooth Surface Code ID 1/2 1369 S
Element Separator AN 1 :
TOO03-5 Tooth Surface Code ID 1/2 1369 S
Segment End B 1 ~
Transaction Set Trailer
TRAILER SE Transaction Set Trailer ID 2 R SE
Element Separator AN 1 *
SE01 Number of Included
Segments
N0 1/10 96 R
Element Separator AN 1 *
SE02 Transaction Set Control
Number
AN 4/9 329 R SE02 must be identical to ST02
Segment End B 1 ~
Functional Group Trailer
GE Functional Group Trailer ID 2 R GE
Element Separator AN 1 *
GE01 Number of Transaction
Sets Included
N0 1/6 97 R
Element Separator AN 1 *
GE02 Group Control Number N0 1/9 28 R GE02 must be identical to GS06
Segment End B 1 ~
Interchange Control Trailer
IEA Interchange Control
Trailer
ID 3 R IEA
Element Separator AN 1 *
IEA01 Number of Included
Functional Groups
N0 1/5 I16 R
Element Separator AN 1 *
IEA02 Interchange Control
Number
N0 9 I12 R Must be identical to the value in
ISA13
Segment End B 1 ~
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
Last Updated: 03/30/2020 Page 34 of 62
2.1. 278 Response
Figure 2-2: 278 Response
Loop Segment
ID
Segment Name/ Data
Element Name Format Length
DE
Ref
#
Req
Des. Value
Interchange Control Record
HEADER ISA Interchange Control
Header
3 R ISA
Element Separator AN 1 *
ISA01 Authorization Information
Qualifier
ID 2 I01 R 00
Element Separator AN 1 *
ISA02 Authorization Information AN 10 I02 R
Element Separator AN 1 *
ISA03 Security Information
Qualifier
ID 2 I03 R 00
Element Separator AN 1 *
ISA04 Security Information AN 10 I04 R
Element Separator AN 1 *
ISA05 Interchange ID Qualifier ID 2 I05 R ZZ=Mutually Defined
Element Separator AN 1 *
ISA06 Interchange Sender ID AN 15 I06 R ID_MMIS_4_DXCMS
Element Separator AN 1 *
ISA07 Interchange ID Qualifier ID 2 I05 R ZZ=Mutually Defined
Element Separator AN 1 *
ISA08 Interchange Receiver ID AN 15 I07 R DXCMS assigned trading partner
ID
Element Separator AN 1 *
ISA09 Interchange Date DT 6 I08 R YYMMDD
Element Separator AN 1 *
ISA10 Interchange Time TM 4 I09 R HHMM
Element Separator AN 1 *
ISA11 Repetition Separator 1 I65 R ^
Element Separator AN 1 *
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
Last Updated: 03/30/2020 Page 35 of 62
Loop Segment
ID
Segment Name/ Data
Element Name Format Length
DE
Ref
#
Req
Des. Value
ISA12 Interchange Version
Number
ID 5 I11 R 00501
Element Separator AN 1 *
ISA13 Interchange Control
Number
N0 9 I12 R
Element Separator AN 1 *
ISA14 Acknowledgment
Requested
ID 1 I13 R 0=No Acknowledgment
Requested
Element Separator AN 1 *
ISA15 Interchange Usage
Indicator
ID 1 I14 R P
Element Separator AN 1 *
ISA16 Component Element
Separator
1 I15 R :
Segment End B 1 ~
Functional Group Header
GS Functional Group Header 2 R GS
Element Separator AN 1 *
GS01 Functional Identifier Code ID 2 479 R HI
Element Separator AN 1 *
GS02 Application Sender's Code AN 2/15 142 R ID_MMIS_4_DXCMS
Element Separator AN 1 *
GS03 Application Receiver's
Code
AN 2/15 124 R DXCMS Assigned trading Partner
ID
Element Separator AN 1 *
GS04 Date DT 8 373 R CCYYMMDD
Element Separator AN 1 *
GS05 Time TM 4/8 337 R HHMM
Element Separator AN 1 *
GS06 Group Control Number N0 1/9 28 R Assigned by Sender
Element Separator AN 1 *
GS07 Responsible Agency Code ID 1/2 455 R X
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
Last Updated: 03/30/2020 Page 36 of 62
Loop Segment
ID
Segment Name/ Data
Element Name Format Length
DE
Ref
#
Req
Des. Value
Element Separator AN 1 *
GS08 Version / Release Code AN 1/12 480 R 005010X217
Segment End B 1 ~
Transaction Set Header
ST Transaction Set Header 2 R ST
Element Separator AN 1 *
ST01 Transaction Set Identifier
Code
ID 3 143 R 278
Element Separator AN 1 *
ST02 Transaction Set Control
Number
AN 4/9 329 R Sequential number assigned by
sender
Element Separator AN 1 *
ST03 Implementation
Convention Reference
AN 1/35 1705 R 005010X217
Segment End B 1 ~
Beginning of Hierarchical Transaction
BHT Beginning Hierarchical
Transaction Segment
ID 3 R BHT
Element Separator AN 1 *
BHT01 Hierarchical Structure
Code
ID 4 1005 R 0078
Element Separator AN 1 *
BHT02 Transaction Set Purpose
Code
ID 2 353 R 11
Element Separator AN 1 *
BHT03 Reference identification AN 1/30 127 R Submitter Transaction
Identifier. Value from the
original 278 request.
Element Separator AN 1 *
BHT04 Date DT 8 373 R CCYYMMDD
Transaction Set Creation Date
Element Separator AN 1 *
BHT05 Time TM 4/8 337 R HHMM
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
Last Updated: 03/30/2020 Page 37 of 62
Loop Segment
ID
Segment Name/ Data
Element Name Format Length
DE
Ref
#
Req
Des. Value
Transaction Set Creation Time
Element Separator AN 1 *
BHT06 Transaction Type Code ID 2/2 640 S 18 = No further updates to
follow
19 = Further updates to follow
Segment End B 1 ~
UMO (Loop 2000A)
2000A HL Hierarchical Level
Segment
ID 2 R HL
Element Separator AN 1 *
HL01 Hierarchical ID Number AN 1/12 628 R 1
Element Separator AN 1 *
Element Separator AN 1 *
HL03 Hierarchical Level Code ID 1/2 735 R 20 = Information Source
Element Separator AN 1 *
HL04 Hierarchical Child Code ID 1/1 736 R 1
Segment End B 1 ~
2010A NM1 Individual or
Organizational Name
ID 3 R NM1
Element Separator AN 1 *
NM101 Entity Identifier Code ID 2/3 98 R X3 = UMO
Element Separator AN 1 *
NM102 Entity Type Qualifier ID 1/1 1065 R 2
Element Separator AN 1 *
NM103 Name Last or
Organization Name
AN 1/35 1035 R IDAHO MEDICAID
Element Separator AN 1 *
NM104 Name First AN 1/25 1036 S
Element Separator AN 1 *
NM105 Name Middle AN 1/25
Element Separator AN 1 *
Element Separator AN 1 *
NM107 Name Suffix AN 1/10 1039 S
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
Last Updated: 03/30/2020 Page 38 of 62
Loop Segment
ID
Segment Name/ Data
Element Name Format Length
DE
Ref
#
Req
Des. Value
Element Separator AN 1 *
NM108 Identification Code
Qualifier
ID 1/2 66 R PI – Payor Identification
Element Separator AN 1 *
NM109 Identification Code AN 2/80 67 R ID_MMIS_4MOLINA
Segment End B 1 ~
Requester (Loop 2000B)
2000B HL Hierarchical Level
Segment
ID 2 R HL
Element Separator AN 1 *
HL01 Hierarchical ID Number AN 1/12 628 R 2
Element Separator AN 1 *
HL02 Hierarchical Parent ID
Number
AN 1/12 734 R 1
Element Separator AN 1 *
HL03 Hierarchical Level Code ID 1/2 735 R 21=Information Receiver
Element Separator AN 1 *
HL04 Hierarchical Child Code ID 1/1 736 R 1
Segment End B 1 ~
2010B NM1 Individual or
Organizational Name
ID 3 R NM1 - segment populated from
Request
Element Separator AN 1 *
NM101 Entity Identifier Code ID 2/3 98 R 1P=Provider, FA=Facility
Element Separator AN 1 *
NM102 Entity Type Qualifier ID 1 1065 R 1=Person, 2=Non-Person Entity
Element Separator AN 1 *
NM103 Name Last or
Organization Name
AN 1/60 1035 S
Element Separator AN 1 *
NM104 Name First AN 1/35 1036 S
Element Separator AN 1 *
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
Last Updated: 03/30/2020 Page 39 of 62
Loop Segment
ID
Segment Name/ Data
Element Name Format Length
DE
Ref
#
Req
Des. Value
NM105 Name Middle AN 1/25 1037 S Use if NM104 is present and the
middle name/initial of the
person is known.
Element Separator AN 1 *
Element Separator AN 1 *
NM107 Name Suffix AN 1/10 1039 S
Element Separator AN 1 *
NM108 Identification Code
Qualifier
ID 1/2 66 R 24=Employer’s Identification
Number
XX = NPI
Element Separator AN 1 *
NM109 Identification Code AN 2/80 67 R NPI or if provider is atypical,
use EIN
Segment End B 1 ~
2010B REF Reference Identification ID 3 S REF - segment populated from
Request
Element Separator AN 1 *
REF01 Reference Identification
Qualifier
ID 2/3 128 R N5
Element Separator AN 1 *
REF02 Reference Identification AN 1/50 127 R Medicaid assigned provider ID
for the Requesting Provider –
for Atypical providers only
Segment End B 1 ~
2010CA AAA Subscriber Request
Validation
ID 3 S AAA
Element Separator AN 1 *
AAA01 Yes/No Condition or
Response Code
ID 1 1073 R N = No
Element Separator AN 1 *
Element Separator AN 1 *
AAA03 Reject Reason Code ID 2 901 R
Element Separator AN 1 *
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
Last Updated: 03/30/2020 Page 40 of 62
Loop Segment
ID
Segment Name/ Data
Element Name Format Length
DE
Ref
#
Req
Des. Value
AAA04 Follow-up Action Code ID 1 889 R
Segment End B 1 ~
Subscriber (Loop 2000C)
2000C HL Hierarchical Level
Segment
ID 2 R HL
Element Separator AN 1 *
HL01 Hierarchical ID Number AN 1/12 628 R 3
Element Separator AN 1 *
HL02 Hierarchical Parent ID
Number
AN 1/12 734 R 2
Element Separator AN 1 *
HL03 Hierarchical Level Code ID 1/2 735 R 22 = Subscriber
Element Separator AN 1 *
HL04 Hierarchical Child Code ID 1 736 R 1
Segment End B 1 ~
2010C NM1 Individual or
Organizational Name
ID 3 R NM1 - populated from Request
Element Separator AN 1 *
NM101 Entity Identifier Code ID 2/3 98 R
Element Separator AN 1 *
NM102 Entity Type Qualifier ID 1 1065 R
Element Separator AN 1 *
NM103 Name Last or
Organization Name
AN 1/50 1035 S
Element Separator AN 1 *
NM104 Name First AN 1/35 1036 S
Element Separator AN 1 *
NM105 Name Middle AN 1/25 1037 S
Element Separator AN 1 *
NM106 Name Prefix AN 1/10 1038 S
Element Separator AN 1 *
NM107 Name Suffix AN 1/10 1039 S
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
Last Updated: 03/30/2020 Page 41 of 62
Loop Segment
ID
Segment Name/ Data
Element Name Format Length
DE
Ref
#
Req
Des. Value
Element Separator AN 1 *
NM108 Identification Code
Qualifier
ID 1/2 66 R
Element Separator AN 1 *
NM109 Identification Code AN 2/80 67 R
Segment End B 1 ~
2010C AAA Subscriber Request
Validation
ID 3 S AAA
Element Separator AN 1 *
AAA01 Yes/No Condition or
Response Code
ID 1 1073 R N = No
Element Separator AN 1 *
Element Separator AN 1 *
AAA03 Reject Reason Code ID 2 901 R
Element Separator AN 1 *
AAA04 Follow-up Action Code ID 1 889 R
Segment End B 1 ~
2010C DMG Demographic Information ID 3 S DMG
Element Separator AN 1 *
DMG01 Date Time Period Format
Qualifier
ID 2/3 1250 R D8
Element Separator AN 1 *
DMG02 Date Time Period AN 1/35 1251 R
Element Separator AN 1 *
DMG03 Gender Code ID 1 1068 S
Segment End B 1 ~
2000E HL Hierarchical Level
Segment
ID 2 R HL - populated from Request
Element Separator AN 1 *
HL01 Hierarchical ID Number AN 1/12 628 R 5
Element Separator AN 1 *
HL02 Hierarchical Parent ID
Number
AN 1/12 734 R 4
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
Last Updated: 03/30/2020 Page 42 of 62
Loop Segment
ID
Segment Name/ Data
Element Name Format Length
DE
Ref
#
Req
Des. Value
Element Separator AN 1 *
HL03 Hierarchical Level Code ID 1/2 735 R EV = Event
Element Separator AN 1 *
HL04 Hierarchical Child Code ID 1 736 R 1
Segment End B 1 ~
2000E TRN Patient Event Tracking
Number Segment
ID 3 S TRN
Element Separator AN 1 *
TRN01 Trace Type Code ID 1/2 481 R 1
Element Separator AN 1 *
TRN02 Reference Identification AN 1/50 127 R
Element Separator AN 1 *
TRN03 Originating Company
Identifier
AN 10 509 R
Element Separator AN 1 *
TRN04 Reference Identification AN 1/50 127 S
Segment End B 1 ~
2000E AAA Subscriber Request
Validation
ID 3 S AAA
Element Separator AN 1 *
AAA01 Yes/No Condition or
Response Code
ID 1 1073 R N = No
Element Separator AN 1 *
Element Separator AN 1 *
AAA03 Reject Reason Code ID 2 901 R
Element Separator AN 1 *
AAA04 Follow-up Action Code ID 1 889 R
Segment End B 1 ~
2000E UM Health Care Services
Review Information
ID 2 R UM
Element Separator AN 1 *
UM01 Request Category Code ID 1/2 1525 R AR = Admission Review
HS = Health Services Review
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
Last Updated: 03/30/2020 Page 43 of 62
Loop Segment
ID
Segment Name/ Data
Element Name Format Length
DE
Ref
#
Req
Des. Value
Element Separator AN 1 *
UM02 Certification Type Code ID 1/1 1322 R I = Initial
3 = Cancel
4 = Extension
Element Separator AN 1 *
UM03 Service Type Code ID 1/2 1365 R For Prior Authorizations, see
UM03 Service Type PA
Crosswalk in this guide
Element Separator AN 1 *
UM04 Health Care Service
Location Information
ID C023 S
UM04-1 Facility Code Value AN 1/2 1331 R
Component Element
Separator
1 :
UM04-2 Facility Code Qualifier ID 1/2 1332 R
Element Separator AN 1 *
Element Separator AN 1 *
UM06 Level of Service Code ID 1/3 1338 S
Segment End B 1 ~
2000E HCR Health Care Services
Review
ID 3 S HCR
Element Separator AN 1 *
HCR01 Action Code ID 1/2 306 R
Element Separator AN 1 *
HCR02 Reference Identification AN 1/50 127 S
Element Separator AN 1 *
HCR03 Industry Code AN 1/30 1271 S
Element Separator AN 1 *
HCR04 Yes/No Condition or
Response Code
ID 1 1073 S
Element Separator AN 1 ~
2000E REF Reference Identification ID 3 S REF
Element Separator AN 1 *
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
Last Updated: 03/30/2020 Page 44 of 62
Loop Segment
ID
Segment Name/ Data
Element Name Format Length
DE
Ref
#
Req
Des. Value
REF01 Reference Identification
Qualifier
ID 2/3 128 R BB = Authorization Number
Element Separator AN 1 *
REF02 Reference Identification AN 1/50 127 R
Element Separator AN 1 ~
2000E DTP Date or Time or Period ID 3 S DTP
Element Separator AN 1 *
DTP01 Date/Time Qualifier ID 3 374 R 439 = Accident
Element Separator AN 1 *
DTP02 Date Time Period Format
Qualifier
ID 2/3 1250 R D8 = date expressed in format
CCYYMMDD
Element Separator AN 1 *
DTP03 Date Time Period AN 1/35 1251 R format = CCYYMMDD
Segment End B 1 ~
2000E DTP Date or Time or Period ID 3 S DTP
Element Separator AN 1 *
DTP01 Date/Time Qualifier ID 3 374 R 484 = Last Menstrual Period
Element Separator AN 1 *
DTP02 Date Time Period Format
Qualifier
ID 2/3 1250 R D8 = date expressed in format
CCYYMMDD
Element Separator AN 1 *
DTP03 Date Time Period AN 1/35 1251 R format = CCYYMMDD
Segment End B 1 ~
2000E DTP Date or Time or Period ID 3 S DTP
Element Separator AN 1 *
DTP01 Date/Time Qualifier ID 3 374 R ABC = Estimated Date of Birth
Element Separator AN 1 *
DTP02 Date Time Period Format
Qualifier
ID 2/3 1250 R D8 = date expressed in format
CCYYMMDD
Element Separator AN 1 *
DTP03 Date Time Period AN 1/35 1251 R format = CCYYMMDD
Segment End B 1 ~
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
Last Updated: 03/30/2020 Page 45 of 62
Loop Segment
ID
Segment Name/ Data
Element Name Format Length
DE
Ref
#
Req
Des. Value
2000E DTP Date or Time or Period ID 3 S DTP
Element Separator AN 1 *
DTP01 Date/Time Qualifier ID 3 374 R 431 = Onset of Current
Symptoms or Illness
Element Separator AN 1 *
DTP02 Date Time Period Format
Qualifier
ID 2/3 1250 R D8 = date expressed in format
CCYYMMDD
Element Separator AN 1 *
DTP03 Date Time Period AN 1/35 1251 R format = CCYYMMDD
Segment End B 1 ~
2000E DTP Date or Time or Period ID 3 S DTP
Element Separator AN 1 *
DTP01 Date/Time Qualifier ID 3 374 R AAH = Event
Element Separator AN 1 *
DTP02 Date Time Period Format
Qualifier
ID 2/3 1250 R D8 = date expressed in format
CCYYMMDD
RD8 = date expressed in format
CCYYMMDD-CCYYMMDD
Element Separator AN 1 *
DTP03 Date Time Period AN 1/35 1251 R format = CCYYMMDD if DTP02
= D8
format = CCYYMMDD-
CCYYMMDD if DTP02 = RD8
Segment End B 1 ~
2000E DTP Date or Time or Period ID 3 S DTP
Element Separator AN 1 *
DTP01 Date/Time Qualifier ID 3 374 R 435 =Admission
Element Separator AN 1 *
DTP02 Date Time Period Format
Qualifier
ID 2/3 1250 R D8 = date expressed in format
CCYYMMDD
RD8 = date expressed in format
CCYYMMDD-CCYYMMDD
Element Separator AN 1 *
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
Last Updated: 03/30/2020 Page 46 of 62
Loop Segment
ID
Segment Name/ Data
Element Name Format Length
DE
Ref
#
Req
Des. Value
DTP03 Date Time Period AN 1/35 1251 R format = CCYYMMDD if DTP02
= D8
format = CCYYMMDD-
CCYYMMDD if DTP02 = RD8
Segment End B 1 ~
2000E DTP Date or Time or Period ID 3 S DTP
Element Separator AN 1 *
DTP01 Date/Time Qualifier ID 3 374 R 096 = Discharge
Element Separator AN 1 *
DTP02 Date Time Period Format
Qualifier
ID 2/3 1250 R D8 = date expressed in format
CCYYMMDD
Element Separator AN 1 *
DTP03 Date Time Period AN 1/35 1251 R format = CCYYMMDD
Segment End B 1 ~
2000E HI Health Care Information
Codes
ID 2 S HI
Element Separator AN 1 *
HI01 Health Care Code
Information – Alias
Diagnosis 1
ID 4 C022 S
HI01-1 Code List Qualifier Code ID 1/3 1270 R BK (ICD-9) – Principal Diagnosis
ABK (ICD-10) – Principal
Diagnosis
BF (ICD-9) - Diagnosis
ABF (ICD-10) - Diagnosis
BJ (ICD-9) –Admitting Diagnosis
ABJ (ICD-10) – Admitting
Diagnosis
Component Element
Separator
1 :
HI01-2 Industry Code AN 1/30 1271 R Diagnosis Code
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
Last Updated: 03/30/2020 Page 47 of 62
Loop Segment
ID
Segment Name/ Data
Element Name Format Length
DE
Ref
#
Req
Des. Value
Component Element
Separator
1 :
HI01-3 Date Time Period Format
Qualifier
ID 2/3 1250 S D8 = date expressed in format
CCYYMMDD
Component Element
Separator
1 :
HI01-4 Date Time Period AN 1/35 1251 S Diagnosis Date. Format date
CCYYMMDD
Element Separator AN 1 *
HI02 Health Care Code
Information – Alias
Diagnosis 2
ID 4 C022 S
HI02-1 Code List Qualifier Code ID 1/3 1270 R BF (ICD-9) - Diagnosis
ABF (ICD-10) - Diagnosis
BJ (ICD-9) –Admitting Diagnosis
ABJ (ICD-10) – Admitting
Diagnosis
Component Element
Separator
1 :
HI02-2 Industry Code AN 1/30 1271 R Diagnosis Code
Component Element
Separator
1 :
HI02-3 Date Time Period Format
Qualifier
ID 2/3 1250 S D8 = date expressed in format
CCYYMMDD
Component Element
Separator
1 :
HI02-4 Date Time Period AN 1/35 1251 S Diagnosis Date. Format date
CCYYMMDD
Element Separator AN 1 *
HI03 Health Care Code
Information – Alias
Diagnosis 3
ID 4 C022 S
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
Last Updated: 03/30/2020 Page 48 of 62
Loop Segment
ID
Segment Name/ Data
Element Name Format Length
DE
Ref
#
Req
Des. Value
HI03-1 Code List Qualifier Code ID 1/3 1270 R BF (ICD-9) - Diagnosis
ABF (ICD-10) - Diagnosis
Component Element
Separator
1 :
HI03-2 Industry Code AN 1/30 1271 R Diagnosis Code
Component Element
Separator
1 :
HI03-3 Date Time Period Format
Qualifier
ID 2/3 1250 S D8 = date expressed in format
CCYYMMDD
Component Element
Separator
1 :
HI03-4 Date Time Period AN 1/35 1251 S Diagnosis Date. Format date
CCYYMMDD
Note: Can be up to 10 HI0x-1
thru HI0x-4 BF/ABF (Other
Diagnosis Code) elements
separated by *
Segment End B 1 ~
2000E HSD Health Care Delivery
Services
ID 3 S HSD
Element Separator AN 1 *
HSD01 Quantity Qualifier ID 2 673 S
Element Separator AN 1 *
HSD02 Quantity R 1/15 380 S
Element Separator AN 1 *
HSD03 Unit or Basis for
Measurement Code
ID 2 355 S
Element Separator AN 1 *
HSD04 Sample Selection Modulus R 1/6 1167 S
Element Separator AN 1 *
HSD05 Time Period Qualifier ID 1/2 615 S
Element Separator AN 1 *
HSD06 Number of Periods N0 1/3 616 S
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
Last Updated: 03/30/2020 Page 49 of 62
Loop Segment
ID
Segment Name/ Data
Element Name Format Length
DE
Ref
#
Req
Des. Value
Element Separator AN 1 *
HSD07 Ship/Delivery or Calendar
Pattern Code
ID 1/2 678 S
Element Separator AN 1 *
HSD08 Ship/Delivery Pattern
Time Code
ID 1 679 S
Segment End B 1 ~
2000E CL1 Claim Codes ID 3 S CL1
Element Separator AN 1 *
CL101 Admission Type Code ID 1 1315 S
Element Separator AN 1 *
CL102 Admission Source Code R 1 1314 S
Element Separator AN 1 *
CL103 Patient Status Code ID ½ 1352 S
Element Separator AN 1 *
CL104 Nursing Home Residential
Status Code
ID 1 1345 S
Segment End B 1 ~
2000E CR1 Ambulance Certification ID 3 S CR1
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
CR103 Ambulance Transport
Code
ID 1 1316 R
Element Separator AN 1 *
CR104 Ambulance Transport
Reason Code
ID 1 1317 R
Element Separator AN 1 *
CR105 Unit or Basis for
Measurement Code
ID 2 355 S
Element Separator AN 1 *
CR106 Quantity R 1/15 380 S
Segment End B 1 ~
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
Last Updated: 03/30/2020 Page 50 of 62
Loop Segment
ID
Segment Name/ Data
Element Name Format Length
DE
Ref
#
Req
Des. Value
2000E CR2 Chiropractic Certification ID 3 S CR2
Element Separator AN 1 *
CR201 Count N0 1/9 609 S
Element Separator AN 1 *
CR202 Quantity R 1/15 380 S
Element Separator AN 1 *
CR203 Subluxation Level Code ID 2/3 1367 S
Element Separator AN 1 *
CR204 Subluxation Level Code ID 2/3 1367 S
Element Separator AN 1 ~
2000E CR6 Home Health Care
Certification
ID 3 S CR6
Element Separator AN 1 *
CR601 Prognosis Code ID 1 923 R
Element Separator AN 1 *
CR602 Date DT 8 373 R format CCYYMMDD
Element Separator AN 1 *
CR603 Date Time Period Format
Qualifier
ID 2/3 1250 S RD8
Element Separator AN 1 *
CR604 Date Time Period AN 1/35 1251 S format CCYYMMDD-CCYYMMDD
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
CR607 Yes/No Condition or
Response Code
ID 1 1073 R W
Element Separator AN 1 *
CR608 Certification Type Code ID 1 1322 R
Element Separator AN 1 ~
2010EA NM1 Individual or
Organizational Name
ID 3 R NM1
Element Separator AN 1 *
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
Last Updated: 03/30/2020 Page 51 of 62
Loop Segment
ID
Segment Name/ Data
Element Name Format Length
DE
Ref
#
Req
Des. Value
NM101 Entity Identifier Code ID 2/3 98 R
Element Separator AN 1 *
NM102 Entity Type Qualifier ID 1 1065 R 1=Person, 2=Non-Person Entity
Element Separator AN 1 *
NM103 Name Last or
Organization Name
AN 1/60 1035 S
Element Separator AN 1 *
NM104 Name First AN 1/35 1036 S Required if NM102=1 & NM103
is present
Element Separator AN 1 *
NM105 Name Middle AN 1/25 1037 S Only used if NM102=1
Element Separator AN 1 *
NM106 Name Prefix AN 1/10 1038 S
Element Separator AN 1 *
NM107 Name Suffix AN 1/10 1039 S
Element Separator AN 1 *
NM108 Identification Code
Qualifier
ID 1/2 66 S 24=Employer’s Identification
Number (for atypical providers
only)
XX= National Provider Identifier
Element Separator AN 1 *
NM109 Identification Code AN 2/80 67 S Enter NPI or if provider is
atypical enter Employer
Identification Number
Segment End B 1 ~
2010EA REF Reference Information ID 3 S REF
Element Separator AN 1 *
REF01 Reference Identification
Qualifier
ID 2/3 128 R N5 = Provider Plan Network
Identifier
Element Separator AN 1 *
REF02 Reference Identification AN 1/50 127 R Used for atypical providers only,
to enter their assigned Provider
ID
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
Last Updated: 03/30/2020 Page 52 of 62
Loop Segment
ID
Segment Name/ Data
Element Name Format Length
DE
Ref
#
Req
Des. Value
Segment End B 1 ~
2010EA AAA Request Validation ID 3 S AAA
Element Separator AN 1 *
AAA01 Yes/No Condition or
Response Code
ID 1 1073 R N = No
Element Separator AN 1 *
Element Separator AN 1 *
AAA03 Reject Reason Code ID 2 901 R
Element Separator AN 1 *
AAA04 Follow-up Action Code ID 1 889 R
Segment End B 1 ~
2010EB NM1 Individual or
Organizational Name
ID 3 R NM1
Element Separator AN 1 *
NM101 Entity Identifier Code ID 2/3 98 R
Element Separator AN 1 *
NM102 Entity Type Qualifier ID 1 1065 R 1=Person
2=Non-Person Entity
Element Separator AN 1 *
NM103 Name Last or
Organization Name
AN 1/60 1035 S
Element Separator AN 1 *
NM104 Name First AN 1/35 1036 S Required if NM102=1 & NM103
is present
Element Separator AN 1 *
NM105 Name Middle AN 1/25 1037 S Only used if NM104 is valued
and middle name/initial is
known
Element Separator AN 1 *
Element Separator AN 1 *
NM107 Name Suffix AN 1/10 1039 S
Element Separator AN 1 *
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
Last Updated: 03/30/2020 Page 53 of 62
Loop Segment
ID
Segment Name/ Data
Element Name Format Length
DE
Ref
#
Req
Des. Value
NM108 Identification Code
Qualifier
ID 1/2 66 S 24=Employer’s Identification
Number (for atypical providers
only)
XX= National Provider Identifier
Element Separator AN 1 *
NM109 Identification Code AN 2/80 67 S Enter NPI or if provider is
atypical enter Employer
Identification Number
Segment End B 1 ~
2010EC NM1 Individual or
Organizational Name
ID 3 R NM1
Element Separator AN 1 *
NM101 Entity Identifier Code ID 2/3 98 R
Element Separator AN 1 *
NM102 Entity Type Qualifier ID 1 1065 R 2=Non-Person Entity
Element Separator AN 1 *
NM103 Name Last or
Organization Name
AN 1/60 1035 S
Segment End B 1 ~
2010EC AAA Request Validation ID 3 S AAA
Element Separator AN 1 *
AAA01 Yes/No Condition or
Response Code
ID 1 1073 R N = No
Element Separator AN 1 *
Element Separator AN 1 *
AAA03 Reject Reason Code ID 2 901 R
Element Separator AN 1 *
AAA04 Follow-up Action Code ID 1 889 R
Segment End B 1 ~
Service (Loop 2000F)
2000F HL Hierarchical Level
Segment
ID 2 R HL - populated from Request
Element Separator AN 1 *
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
Last Updated: 03/30/2020 Page 54 of 62
Loop Segment
ID
Segment Name/ Data
Element Name Format Length
DE
Ref
#
Req
Des. Value
HL01 Hierarchical ID Number AN 1/12 628 R 6
Element Separator AN 1 *
HL02 Hierarchical Parent ID
Number
AN 1/12 734 R 5
Element Separator AN 1 *
HL03 Hierarchical Level Code ID 1/2 735 R SS=Services
Element Separator AN 1 *
HL04 Hierarchical Child Code ID 1/1 736 R 0
Segment End B 1 ~
2000F AAA Service Request
Validation
ID 3 S AAA
Element Separator AN 1 *
AAA01 Yes/No Condition or
Response Code
ID 1/1 1073 R N = No
Element Separator AN 1 *
Element Separator AN 1 *
AAA03 Reject Reason Code ID 2 901 R
Element Separator AN 1 *
AAA04 Follow-up Action Code ID 1 889 R
Segment End B 1 ~
2000F HCR Health Care Services
Review
ID 3 S HCR
Element Separator AN 1 *
HCR01 Action Code ID 1/2 306 R
Element Separator AN 1 *
HCR02 Reference Identification AN 1/50 127 S
Element Separator AN 1 *
HCR03 Industry Code AN 1/30 1271 S
Element Separator AN 1 *
HCR04 Yes/No Condition or
Response Code
ID 1 1073 S
Element Separator AN 1 ~
2000F DTP Date or Time or Period ID 3 S DTP - populated from Request
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
Last Updated: 03/30/2020 Page 55 of 62
Loop Segment
ID
Segment Name/ Data
Element Name Format Length
DE
Ref
#
Req
Des. Value
Element Separator AN 1 *
DTP01 Date/Time Qualifier ID 3 374 R 472 - Service
Element Separator AN 1 *
DTP02 Date Time Period Format
Qualifier
ID 2/3 1250 R D8 - CCYYMMDD
RD8 - CCYYMMDD-CCYYMMDD
Element Separator AN 1 *
DTP03 Date Time Period AN 1/35 1251 R CCYYMMDD if DTP02 = D8
CCYYMMDD-CCYYMMDD if
DTP02 = RD8
Segment End B 1 ~
2000F DTP Date or Time or Period ID 3 S DTP
Element Separator AN 1 *
DTP01 Date/Time Qualifier ID 3 374 R 102 - Issue
Element Separator AN 1 *
DTP02 Date Time Period Format
Qualifier
ID 2/3 1250 R D8 - CCYYMMDD
Element Separator AN 1 *
DTP03 Date Time Period AN 1/35 1251 R
Segment End B 1 ~
2000F DTP Date or Time or Period ID 3 S DTP
Element Separator AN 1 *
DTP01 Date/Time Qualifier ID 3 374 R 036 - Expiration
Element Separator AN 1 *
DTP02 Date Time Period Format
Qualifier
ID 2/3 1250 R D8 - CCYYMMDD
Element Separator AN 1 *
DTP03 Date Time Period AN 1/35 1251 R
Segment End B 1 ~
2000F DTP Date or Time or Period ID 3 S DTP
Element Separator AN 1 *
DTP01 Date/Time Qualifier ID 3 374 R 007 - Effective
Element Separator AN 1 *
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Loop Segment
ID
Segment Name/ Data
Element Name Format Length
DE
Ref
#
Req
Des. Value
DTP02 Date Time Period Format
Qualifier
ID 2/3 1250 R D8 - CCYYMMDD
RD8 – CCYYMMDD-CCYYMMDD
Element Separator AN 1 *
DTP03 Date Time Period AN 1/35 1251 R CCYYMMDD if DTP02 = D8
CCYYMMDD-CCYYMMDD if
DTP02 = RD8
Segment End B 1 ~
2000F SV1 Professional Service ID 3 S SV1
Element Separator AN 1 *
SV101 Composite Medical
Procedure Identifier
C003 R
SV101-1 Product/Service ID
Qualifier
ID 2 235 R HC = HCPCS Code
Element Separator AN 1 :
SV101-2 Product/Service ID AN 1/48 234 R
Element Separator AN 1 :
SV101-3 Procedure Modifier AN 2 1339 S
Element Separator AN 1 :
SV101-4 Procedure Modifier AN 2 1339 S
Element Separator AN 1 :
SV101-5 Procedure Modifier AN 2 1339 S
Element Separator AN 1 :
SV101-6 Procedure Modifier AN 2 1339 S
Element Separator AN 1 :
SV101-7 Description AN 1/80 352 S
Element Separator AN 1 :
SV101-8 Product/Service ID AN 1/48 234 S
Element Separator AN 1 *
SV102 Monetary Amount R 1/18 782 S
Element Separator AN 1 *
SV103 Unit or Basis for
Measurement Code
ID 2 355 S UN = Unit
Element Separator AN 1 *
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
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Loop Segment
ID
Segment Name/ Data
Element Name Format Length
DE
Ref
#
Req
Des. Value
SV104 Quantity R 1/15 380 S
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
SV111 Yes/No Condition or
Response Code
ID 1 1073 S N = No
Y = Yes
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
SV120 Level of Care Code ID 1 1337 S
Segment End B 1 ~
2000F SV2 Institutional Service ID 3 S SV2
Element Separator AN 1 *
SV201 Product/Service ID AN 1/48 234 S
Element Separator AN 1 *
SV202 Composite Medical
Procedure Identifier
C003 S
SV202-1 Product/Service ID
Qualifier
ID 2 235 R HC = HCPCS Code
Element Separator AN 1 :
SV202-2 Product/Service ID AN 1/48 234 R
Element Separator AN 1 :
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Loop Segment
ID
Segment Name/ Data
Element Name Format Length
DE
Ref
#
Req
Des. Value
SV202-3 Procedure Modifier AN 2 1339 S
Element Separator AN 1 :
SV202-4 Procedure Modifier AN 2 1339 S
Element Separator AN 1 :
SV202-5 Procedure Modifier AN 2 1339 S
Element Separator AN 1 :
SV202-6 Procedure Modifier AN 2 1339 S
Element Separator AN 1 :
SV202-7 Description AN 1/80 352 S
Element Separator AN 1 :
SV202-8 Product/Service ID AN 1/48 234 S
Element Separator AN 1 *
SV203 Monetary Amount R 1/18 782 S
Element Separator AN 1 *
SV204 Unit or Basis for
Measurement Code
ID 2 355 S DA =Days
UN = Unit
Element Separator AN 1 *
SV205 Quantity R 1/15 380 S
Element Separator AN 1 *
SV206 Unit Rate R 1/10 1371 S
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
SV210 Level of Care Code ID 1 1337 S
Segment End B 1 ~
2000F SV3 Dental Service ID 3 S SV3
Element Separator AN 1 *
SV301 Composite Medical
Procedure Identifier
C003 R
SV301-1 Product/Service ID
Qualifier
ID 2 235 R AD = American Dental
Association Codes
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Loop Segment
ID
Segment Name/ Data
Element Name Format Length
DE
Ref
#
Req
Des. Value
Element Separator AN 1 :
SV301-2 Product/Service ID AN 1/48 234 R
Element Separator AN 1 :
SV301-3 Procedure Modifier AN 2 1339 S
Element Separator AN 1 :
SV301-4 Procedure Modifier AN 2 1339 S
Element Separator AN 1 :
SV301-5 Procedure Modifier AN 2 1339 S
Element Separator AN 1 :
SV301-6 Procedure Modifier AN 2 1339 S
Element Separator AN 1 :
SV301-7 Description AN 1/80 352 S
Element Separator AN 1 :
SV301-8 Product/Service ID AN 1/48 234 S
Element Separator AN 1 *
SV302 Monetary Amount R 1/18 782 S
Element Separator AN 1 *
Element Separator AN 1 *
SV304 Oral Cavity Designation C006 S
Element Separator AN 1 :
SV304-1 Oral Cavity Designation
Code
ID 1/3 1361 R
Element Separator AN 1 :
SV304-2 Oral Cavity Designation
Code
ID 1/3 1361 S
Element Separator AN 1 :
SV304-3 Oral Cavity Designation
Code
ID 1/3 1361 S
Element Separator AN 1 :
SV304-4 Oral Cavity Designation
Code
ID 1/3 1361 S
Element Separator AN 1 :
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Loop Segment
ID
Segment Name/ Data
Element Name Format Length
DE
Ref
#
Req
Des. Value
SV304-5 Oral Cavity Designation
Code
ID 1/3 1361 S
Element Separator AN 1 *
SV305 Prosthesis, Crown or Inlay
Code
ID 1 1358 S I = Initial Placement
R = Replacement
Element Separator AN 1 *
SV306 Quantity R 1/15 380 R
Element Separator AN 1 *
SV307 Description AN 1/80 352 S
Element Separator AN 1 *
2000F TOO Tooth Identification ID 3 S TOO
Element Separator AN 1 *
TOO01 Code List Qualifier Code ID 1/3 1270 R JP = Universal National Tooth
Designation System
Element Separator AN 1 *
TOO02 Industry Code AN 1/30 1271 R
Element Separator AN 1 *
TOO03 Tooth Surface C005 S
TOO03-1 Tooth Surface Code ID 1/2 1369 R
Element Separator AN 1 :
TOO03-2 Tooth Surface Code ID ½ 1369 S
Element Separator AN 1 :
TOO03-3 Tooth Surface Code ID 1/2 1369 S
Element Separator AN 1 :
TOO03-4 Tooth Surface Code ID 1/2 1369 S
Element Separator AN 1 :
TOO03-5 Tooth Surface Code ID 1/2 1369 S
Segment End B 1 ~
Transaction Set Trailer
TRAILER SE Transaction Set Trailer ID 2 R SE
SE01 Number of Included
Segments
N0 1/10 96 R
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Loop Segment
ID
Segment Name/ Data
Element Name Format Length
DE
Ref
#
Req
Des. Value
Element Separator AN 1 *
SE02 Transaction Set Control
Number
AN 4/9 329 R must equal ST02 on transaction
header
Segment End B 1 ~
Functional Group Trailer
GE Functional Group Trailer ID 2 R GE
GE01 Number of Transaction
Sets Included
N0 1/6 97 R
Element Separator AN 1 *
GE02 Group Control Number N0 1/9 28 R
Segment End B 1 ~
Interchange Control Trailer
IEA Interchange Control
Trailer
ID 3 R IEA
IEA01 Number of Included
Functional Groups
N0 1/5 I16 R
Element Separator AN 1 *
IEA02 Interchange Control
Number
N0 9 I12 R
Segment End B 1 ~
Idaho MMIS 278 Healthcare Services Request for Review and Response-5010
Last Updated: 03/30/2020 Page 62 of 62
Appendix A.
Please see Appendix_A_Vendor_Specs-5010.docx.